Every finding on record at HRH Transitional Care Unit(A D/B/A Entity of Hrhs)

Based on clinical record review, observation, and staff interview, it was determined that the facility failed to assess residents for side rail use, review the risks and benefits of side rail use, and obtain informed consent from the resident or responsible party for use of side rails for four of nine sampled residents. (Resident 4, 36, 37, 38) Findings include: Clinical record review revealed that Resident 4 was admitted to the facility on [DATE], with diagnoses that included arthritis and abnormalities of gait and mobility. A Minimum Data Set assessment completed January 21, 2026, revealed that the resident had no memory impairment and required moderate assistance of staff for bed mobility. On February 17, 2026, at 12:42 p.m., and 2:25 p.m., the resident was observed in bed with two side rails in the upright position. There was no documented evidence to support that an assessment was completed for side rail use, that the risk and benefits of side rail use were reviewed, or that informed consent was obtained from the resident or resident's responsible party prior to the use of the side rails. Clinical record review revealed that Resident 36 was admitted to the facility on [DATE], with diagnoses that included a right hip fracture. Clinical record documentation indicated that Resident 36 had no memory impairment and required supervisory assistance from staff for bed mobility. On February 17, 2026, at 2:22 p.m., and February 18, 2026, at 8:45 a.m., the resident was observed in bed with two side rails in the upright position. There was no documented evidence to support that an assessment was completed for side rail use or that the risk and benefits of side rail use were reviewed or that informed consent was obtained from the resident or resident's responsible party prior to the use of the side rails. Clinical record review revealed that Resident 37 was admitted to the facility on [DATE], with diagnoses that included a right thigh fracture. Clinical record documentation indicated that Resident 37 had no memory impairment and required supervisory assistance from staff for bed mobility. On February 18, 2026, at 8:33 a.m., the resident was observed in bed with two side rails in the upright position. There was no documented evidence to support that an assessment was completed for side rail use or that the risk and benefits of side rail use were reviewed or that informed consent was obtained from the resident or resident's responsible party prior to the use of the side rails. Clinical record review revealed that Resident 38 was admitted to the facility on [DATE], with diagnoses that included deconditioning. Clinical record documentation indicated that Resident 38 had no memory impairment and was independent for bed mobility. On February 17, 2026, at 2:24 p.m., and February 18, 2026, at 9:13 a.m., the resident was observed in bed with two side rails in the upright position. There was no documented evidence to support that an assessment was completed for side rail use or that the risk and benefits of side rail use was reviewed or that informed consent were obtained from the resident or resident's responsible party prior to the use of the side rails. In an interview on February 19, 2026, at 9:53 a.m., the Unit Manager confirmed there was no documented evidence to support that attempts to use alternative bed mobility methods were used, that the residents were assessed for bed rail use, and that informed consent discussing risks and benefits of bed rail use was obtained from the resident or resident's representative prior to bed rail use. 28 Pa 211.12(d)(1)(5) Nursing services.

Based on clinical record review and staff interview, it was determined the facility failed to notify the resident's representative(s) of transfer(s), including the reasons for the moves, in writing upon transfer for three of three residents who were transferred out of the facility (Residents 1, 5, and 29) and the facility failed to provide copies of the written discharge notices to a representative of the Office of the Long-Term Care Ombudsman for three of three residents who were discharged from the facility. (Residents 2, 3, and 31)Findings include: Clinical record review revealed that Resident 1 was transferred to the hospital on February 11, 2026, after a change in condition. There was no documented evidence to support that the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital.Clinical record review revealed that Resident 5 was transferred to the hospital on December 5, 2025, after a change in condition. There was no documented evidence to support that the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital.Clinical record review revealed that Resident 29 was transferred to the hospital on January 26, 2026, after a change in condition. There was no documented evidence to support that the resident's responsible party or legal representative was provided with written information regarding the transfer to the hospital.Clinical record review revealed that Resident 2 was discharged from the facility on February 5, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.Clinical record review revealed that Resident 3 was discharged from the facility on January 30, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman. Clinical record review revealed that Resident 31 was discharged from the facility on January 23, 2026. There was no documented evidence that the facility sent copies of the written discharge notice to a representative of the Office of the State Long-Term Care Ombudsman.In an interview on February 19, 2026, at 9:50 a.m., the Unit Manager confirmed that the notification of transfers were not sent for the noted resident representatives and that the written copies of the discharge notices were not sent to the Office of the State Long-Term Care Ombudsman.28 Pa. Code 201.14(a) Responsibility of licensee.28 Pa. Code 201.18(b)(3) Management.

Based on clinical record review and staff interview, it was determined that the facility failed to electronically transmit encoded Minimum Data Set (MDS) data to the Centers for Medicare & Medicaid Services (CMS) within 14 days after the facility completed the resident assessment for two of two residents who had been discharged from the facility. (Residents 1, 3) Findings include: Clinical record review revealed that a discharge MDS assessment was completed on December 4, 2024, for Resident 1, however the record reflected that the MDS had not been exported as of January 15, 2025. Clinical record review revealed that a discharge MDS assessment was completed on December 11, 2024, for Resident 3, however, the record reflected that the MDS had not been exported as of January 15, 2025. In an interview on January 15, 2025, at 9:56 a.m., RN1 stated that the discharge MDS assessments had not been exported and transmitted to the CMS system in a timely manner.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to ensure that physician's orders for the care and maintenance of intravenous catheters were obtained for one of 18 residents reviewed (Resident 114). Findings included, The facility's policy regarding intravenous therapy (IV - a tube placed in a vein that can be used to deliver fluids and/or medications), dated June 22, 2020, included that catheters that were capped were to be maintained using three milliliters (ml) of saline (sterile salt and water solution) by flushing with 3 ml of saline, then administering the antibiotic, then flushing with 3 ml of saline after each use, or at least every eight hours to maintain patency (open/unobstructed). Physician's orders for Resident 114, dated May 1, 2021, included an order to have a peripheral intravenous (IV) catheter inserted. A nursing note dated May 17, 2021, at 6:35 p.m. revealed that the nurse attempted to get an IV in the resident per physician's orders, but multiple attempts were unsuccessful. A nursing note dated May 18, 2021, at 6:33 a.m. revealed that the resident was off the floor for a colonoscopy (an exam using a long, flexible tube inserted into the rectum to detect changes or abnormalities in the large intestine and rectum), and a note at 10:52 a.m. revealed that the resident returned from having a colonoscopy around 9:30 a.m. Observations of Resident 114 on May 27, 2021, at 1:15 p.m. revealed that the resident was lying in bed and had an IV catheter secured with a clear dressing to the back of his left hand. There was no documented evidence that Resident 114's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter. Medication Administration Records (MAR's) and Treatment Administration Records (TAR's) for Resident 114, dated May 2021, revealed no documented evidence that the resident's IV catheter was being cared for in accordance with the facility's policy. Observations of Resident 114 with the Unit Manager on May 28, 2021, at 2:05 p.m confirmed that the resident still had an IV catheter in the back of his left hand. Interview with the Unit Manager at 2:07 p.m. revealed that she saw the order for the resident to have an IV catheter inserted, and saw the nursing note on May 17, 2021, that they were unable to insert the IV catheter. The resident then went to the hospital for a colonoscopy and must have returned with an IV catheter at that time. She confirmed that there was no documented evidence that the resident's physician was contacted for orders regarding the care and maintenance of the resident's IV catheter, and that there was no documented evidence that the resident's IV catheter was being cared for in accordance with the facility's policy. 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to administer pain medications as ordered by the physician for one of 18 residents reviewed (Resident 108). Findings include: physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident 108's Medication Administration Records (MAR's) for May 2021 revealed that on May 25, 2021, at 9:50 a.m. the resident's pain rating was an 8 and staff administered 2 mg of [MEDICATION(S)]. There was no documented evidence that the physician was notified that the resident's pain rating exceeded the ordered pain scale of 4-6, and no documented evidence that an order was received to administer the 2 mg of [MEDICATION(S)] for the resident's current pain rating of 8. Interview with the Nurse Manager on May 28, 2021, at 1:08 p.m. confirmed that Resident 108's pain medication was not administered in accordance with the physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . 28 Pa. Code 211.12(d)(1)(3)(5) Nursing services.

Based on review of policies and clinical records, as well as observations and staff interviews, it was determined that the facility failed to provide an environment that was as free of accident hazards as possible for one of 18 residents reviewed (Resident 112) who was at risk for falls. Findings include: The facility's policy regarding fall prevention and management, dated February 11, 2021, revealed that all residents at risk were to be considered for fall prevention interventions. Possible interventions for all residents included keeping the call bell within reach and instructing the resident to call for assistance with ambulation (walking). A care plan for Resident 112, dated May 25, 2021, revealed that the resident was a fall risk and staff were to follow fall precautions and fall risk protocol. Physician's orders dated May 25, 2021, included and order for staff to follow fall precautions. A fall assessment dated [DATE], at 9:34 a.m. revealed that the resident was at high risk for falls, and the bed should be maintained in a low position, the call bell should be within reach, and the resident should have slip-proof footwear. Observations of Resident 112 on dated May 27, 2021, at 1:30 p.m. revealed that the resident was sitting in his room with his lunch tray in front of him and with his call bell out of his reach. At 2:25 p.m. the resident was sitting in a chair at his bedside and his call bell was out of reach. Interview with Registered Nurse 1 on May 27, 2021, at 2:28 p.m. confirmed that Resident 112's call bell was not within reach of the resident and should have been. 28 Pa. Code 211.11(d)(1) Resident care plan. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to follow physician's orders and care plans for two of 18 residents reviewed (Residents 104, 119) who were to be on intake and output monitoring. Findings include: Physician's orders for Resident 104, dated May 24, 2021, included an order for [MEDICAL RECORD OR PHYSICIAN ORDER] . The resident's care plan, dated May 25, 2021, included an order to monitor the resident's intake and output (I&O - the measurement of a resident's fluid intake by mouth, feeding tubes, or intravenous catheters, and output from kidneys, gastrointestinal tract, drainage tubes, and wounds) every shift until discharged . Review of Resident 104's I&O records for May 25 to 28, 2021, revealed that no intake was recorded for any shifts, and records for May 25, 26 and 27, 2021, revealed that only output was recorded on May 27, 2021. There was no documented evidence that Resident 104's intake and output was being monitored or recorded every shift in accordance with the care plan. Interview with the Director of Nursing on May 28, 2021, at 4:33 p.m. confirmed that there was no documented evidence of intake and output monitoring every shift for Resident 104, per the care plan. An admission assessment for Resident 119, dated May 19, 2021, revealed diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Admission physician's orders, dated May 19, 2021, included an order to monitor the resident's I&O. Review of Resident 119's I&O records for May 19 to 28, 2021, revealed that only the output was recorded. There was no documented evidence that Resident 119's intake was being monitored or recorded in accordance with the physician's orders. Interview with the Director of Nursing on May 28, 2021, at 1:08 p.m. confirmed that there was no documented evidence of intake monitoring for Resident 119 per the physician's order. 28 Pa. Code 211.12(d)(1)(5) Nursing services.

Based on observations, and interviews with staff, it was determined that the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. Findings include: An initial tour of the Food Service Department was conducted on (MONTH) 10, 2019 at 9:25 AM with Employee E3, Food Service Director (FSD), which revealed the following: Observation in the receiving area revealed papers and loose trash around the loading dock and on the ground around the recycling dumpster, and empty soda bottles and trash around the garbage compactor, and an excessive number of cardboard boxes piled in the hall outside the dietary department. Interview with the Food Service Director (FSD) at 9:50 a.m. on (MONTH) 10, 2019, confirmed that the number of boxes was excessive and was due to the cardboard bailer being full. Further observation in the receiving area revealed stacks of crushed cardboard boxes with metal banding holding them in large bundles and the bin holding boxes waiting to be bound was also full. Observations in the walk-in freezer revealed an open box of frozen corn on the cob with the inner plastic bag open and exposed to the circulating air. Observations in the walk-in refrigerator revealed a container of gelatinous dark colored liquid covered with plastic wrap with a label indicating it was Turkey Stock and had a use by date of (MONTH) 8, 2019. Observations in the production area revealed an orange/brownish substance build up on the floor under and behind the combi-oven and tilt-skillet. Interview with FSD at 9:50 a.m. on (MONTH) 10, 2019, confirmed the above findings. Observations in the pot and pan room on (MONTH) 12, 2019, at 9:45 a.m. revealed the pot washing machine which had a brownish buildup of grime on the outside surface of the top of the machine where the door closes, and a heavy buildup of dust on the chemical dispenser mounted on the wall next to the pot washing machine, and black discoloration on the white concrete block wall behind the three compartment pot sink. Observation in the pot sink revealed that when the sanitizer level was tested it was 500 PPM (parts per million), and the EcoLab (chemical company servicing the facility) signage on the wall above the pot sink indicated the sanitizer level should be between 150 and 400 PPM. Interview with FSD on (MONTH) 12, 2019, at 9:50 a.m. confirmed the above findings. The facility failed to store, prepare and serve food in accordance with professional standards for food service safety. 28 Pa. Code: 2014(a) Responsibility of licensee 28 Pa. Code: 201.18(b)(3) Management 28 PA. Code: 207.2(a) Administrator's responsibility

Based on clinical record reviews and interviews with facility staff, it was determined that the facility failed to ensure residents received treatment of [REDACTED]. Findings include: A review of Resident R103's clinical record revealed the resident was admitted to the facility on (MONTH) 4, 2019 with a [DIAGNOSES REDACTED]. During an interview with the resident on (MONTH) 11, 2019 at, 9:00 a.m., the resident wore an immobilizer on her right leg (a removable devise used to restrain the leg from bending). Review of the resident's physician orders [REDACTED]. This was confirmed with the Director of Nursing on (MONTH) 12, 2019 at approximately 3:00 p.m. that the facility failed to obtain orders for the implementation of the immobilizer including the resident's care needs while maintaining the devise. Review of Resident R155's clinical record revealed the resident was admitted to the facility on (MONTH) 7, 2019, with [DIAGNOSES REDACTED]. Observations on (MONTH) 10, 2019 at 1:15 p.m. during a resident interview in the resident's room revealed the resident was exhibiting signs of being in pain and holding her left knee. She stated that she was in pain and that it was her understanding that the reason she was not receiving her [MEDICATION NAME] for her pain, was because it was not on the transfer paperwork from the hospital. Further review of Resident R155's clinical record revealed a transcription report from the hospital containing a medication review which listed [MEDICATION NAME] 200 mg oral capsule, take 1 capsule two times a day along with 14 other medications. A review of Resident R155's physician's orders [REDACTED]. There was no documentation that the resident had received this medicine from her admission on (MONTH) 7, (YEAR) until after noon on (MONTH) 10, 2019. The facility failed to obtain an order for [REDACTED]. It was confirmed with the Director of Nursing on (MONTH) 12, 2019 at approximately 2:50 p.m. that the facility failed to obtain orders for pain medication on admission. The facility failed to ensure residents received treatment of [REDACTED]. Pa. Code 211.5 (f) Clinical records.

Based on clinical record review, resident interview and staff interview, it was determined that the facility failed to make certain the highest practicable level of pain management was maintained for one of 11 residents reviewed (Resident R155). Findings include: Review of Resident R155's clinical record revealed the resident was admitted to the facility on (MONTH) 7, 2019, with [DIAGNOSES REDACTED]. Observations on (MONTH) 10, 2019 at 1:15 p.m. during a resident interview in the resident's room revealed the resident was exhibiting signs of being in pain and holding her left knee which had just had the dressing removed to reveal her large surgical scar with sutures running from the top of her knee to the bottom. Resident R155 stated that she was in pain and had just realized that she had not been getting her [MEDICATION NAME] medication that she had been on for many years due to her arthritic pain in her joints. She stated that she had severe pain in her left knee which had been surgically replaced less than a week ago. She also stated that it was her understanding that the reason she was not receiving her [MEDICATION NAME] was because it was not on the transfer paperwork from the hospital. Further review of Resident R155's clinical record revealed a transcription report from the hospital containing a medication review which listed [MEDICATION NAME] 200 mg oral capsule, take 1 capsule two times a day along with 14 other medications. A review of Resident R155's physician's orders [REDACTED]. The facility failed to make certain the highest practicable level of pain management was maintained. 28 Pa Code:201.14(a) Responsibility of licensee. 28 Pa. Code: 201.29(j) Resident rights. 28 Pa. Code: 211.10(c)(d) Resident care policies. 28 Pa. Code: 211.12(d)(1)(2)(3)(5) Nursing services

Based on review of clinical records, facility policy and procedure, and interviews with facility staff, it was determined the facility failed to ensure that residents' choice of advance directives were reflected in physician orders [REDACTED]. Findings include: A review of Advance Directives dated (MONTH) 29, (YEAR), indicates Federal and Pennsylvania State Law provides that every competent adult has the fundamental right to self-determination regarding decisions pertaining to his or her own health, including the right to choose or refuse medical treatment, and that the Attending Physician will review the Advance Directive during the admission assessment and write appropriate order to assure execution of the patient's current wishes. A review of Resident R103's clinical record revealed the resident was admitted to the facility on (MONTH) 4, 2019, with a [DIAGNOSES REDACTED]. Further review of the resident's medical records revealed no advanced directives were elected since admission. A review of Resident R104's clinical record revealed the resident was admitted to the facility on (MONTH) 3, 2019 with a [DIAGNOSES REDACTED]. Further review of the resident's medical records revealed no advanced directives were elected since admission. On (MONTH) 12, 2019 at, 9:21 a.m., per Registered Nurse, Employee E5 stated, It looks like she has an Advanced Directive that the family said they would bring in but never did and there is no orders for the advance directives in the computer. A review of Resident R105's clinical record revealed the resident was admitted to the facility on (MONTH) 8, 2019, with a [DIAGNOSES REDACTED]. Further review of the resident's hard chart (paper chart) revealed the facility failed to ensure accurate documentation was maintained regarding residents' wishes. An interview with the Director of Nursing (DON) on (MONTH) 12, 2019 at, 2:00 p.m. confirmed the facility failed to formulate the proper Advance Directives for these residents. The DON stated, I know our nursing staff should follow up to confirm we received the advance directives from the residents, its important. We also have to wait for the physcian to talk to the resident regarding their wishes before the doctor places the order. The nursing staff should follow up with the doctors too. A review of Resident R153's clinical record revealed that the resident was admitted to the facility on (MONTH) 7, 2019 with a [DIAGNOSES REDACTED]. taken to revive a person and sustain life). Further review of Resident R153's electronic medical record revealed an active physician's orders [REDACTED]. stops or if the patient's heart stops beating). During an interview with the DON on (MONTH) 12, 2019 at, 2:45 p.m. verified that the current physician order [REDACTED]. The facility failed to ensure that a resident's choice of advance directives were obtained and/or accurately reflected in the residents' physician orders. 28 PA Code: 201.29(a) (i) Resident rights. 28 Pa. Code 201.18(b)(1) Management 28 Pa. Code 211.5(f) Clinical records 28 Pa. Code 211.12(d)(1)(5) Nursing services

Based on review of residents' clinical records, facility policy and procedures and interviews with staff it was determined that the facility failed to develop a comprehensive care plan that included residents goals, interventions and objectives to meet the residents medical, nursing, mental and psychosocial needs for two out of 11 clinical records reviewed (Resident R102 and R154). Findings include: Review of the facility s policy titled, Assessment and Plan of Care Policy revised in (MONTH) 2013 states, To provide quality care to the patients as determined by their individual needs. All care, treatment and activities are planned with respect to the individual patient's philosophies and wishes. Evaluation of prospective patients shall be made prior to admission to ensure that patients are admitted whose medical and psychosocial needs can be met by the facility. A review of Resident R103's clinical record revealed the resident was admitted to the facility on (MONTH) 4, 2019, with a [DIAGNOSES REDACTED]. During an interview with the resident on (MONTH) 11, 2019 at, 9:00 a.m., the resident wore an immobilizer on her right leg (a removable devise used to restrain the leg from bending). Review of the resident's care plan revealed the facility failed to implement a plan of care for the immobilizer which should have included a comprehensive plan specifying the resident's care needs. This was confirmed with the Director of Nursing (DON) on (MONTH) 12, 2019 at approximately 3:00 p.m. that the facility failed to implement a plan of care specifically designed for the resident's care needs while maintaining the devise. A review of Resident R154's clinical record revealed the resident was admitted to the facility on (MONTH) 29, 2019, with a [DIAGNOSES REDACTED]. During an interview with the resident on (MONTH) 11, 2019 at, 11:00 a.m., the resident was wearing knee high elastic stockings. Further review of the resident's medical record revealed [REDACTED]. Review of the resident's care plan revealed the facility failed to implement a comprehensive plan of care for the elastic knee high [MEDICATION NAME] stockings. It was confirmed with the Director of Nursing (DON) on (MONTH) 12, 2019 at approximately 2:00 p.m. that the facility failed to implement a plan of care specifically designed for the resident's care needs related to [MEDICAL CONDITION] control with the specialty stockings. The facility failed to develop a comprehensive plan of care specifically created to meet each of the residents' individual care needs. Pa. Code 201.14 (a) Responsibility of licensee. Pa. Code 211.10 (a)(c)(d) Resident Care Policies. Pa. Code 211.11 (a)(b)(c)(d) Resident Care Plan. Pa. Code 211.12 (d)(1)(3)(5) Nursing Services. previously cited on 5/24/2018 and 4/20/2017

Based on staff interviews, review of Casper MDS 3.0 Roster, Casper MDS 3.0 Missing OBRA Assessment report and MDS 3.0 NH Final Validation reports, it was determine that resident's assessments were not completed and/or transmitted to CMS within the required time frames. Findings include: On (MONTH) 19, (YEAR) Casper reports were obtained and reviewed. The reports indicated that there were more admission assessments then discharge assessments for the facility. On (MONTH) 21, (YEAR) at approximately 12 PM interview wwith Employee 2 and Employee 3. Employee E2 explained that the facility was behind in completing non-medicare discharge assessments however the facility completed and transmitted resident assessments for the period (MONTH) (YEAR) to (MONTH) (YEAR) on (MONTH) 14, (YEAR). Review of the MDS 3.0 NH Final Validation Report revealed a total of 73 records were submitted on (MONTH) 14, (YEAR). Of the 73 records, approximately 52 were assessments that were not completed within the required time frame; the remaining 21 records were identified as not being submitted within the required time frames. The facility failed to complete required MDS 3.0 resident's assessments and/or transmit the data to CMS within the required time frames. 28 PA Code: 201.18 (e) (6) 28 PA Code: 211.12 (d) (1) (3) (5) Nursing services

Based on review of observations and staff interviews, it was determined that the facility failed to maintain the dumpster area under sanitary conditions. Findings include: A tour of the dumpster area, outside behind the loading dock, was completed accompanied by the Chef and Clinical Nutrition Manager on (MONTH) 21, (YEAR) at approximately 9:30 a.m. Observation revealed that the area around the dumpster/compactor was observed to have debris on ground surounding the compactor. Along the one side of the compactor there were many soiled vinyl gloves, a 10 milleter syringe (without needle), soiled face mask, a clear plastic six pack carrier, soiled mop head, plastic blue and yellow medication caps, empty drink carton, plastic utensils, empty plastic gallon bottle, cardboard and other pieces of papers and debris. On top of the motor housing located on the other side of the compactor were soiled vinyl gloves and a blue cloth rag. This observation was confirmed with the Chef and Clinical Nutrition Manager. The facility failed to maintain the dumpster area under sanitary conditions. 28 Pa. Code: 201.18(a)(b)(1) Management

Based on review of the clinical record, facility documentation, and interviews with resident and facility staff it was determined that the facility failed to ensure that the care plan was developed to reflect the current status of a resident with a new [DIAGNOSES REDACTED]. Findings include: A review of Resident R168's current plan of care revealed physcian progress notes that stated the Resident was admitted to the facility on (MONTH) 18, (YEAR) after a fall at home and was noted to have a history of [MEDICAL CONDITION] and had an indwelling urinary catheter(tube inserted to drain urine). Review of the plan of care to address the use of the indwelling urinary catheter included the use of a privacy bag. Observation of the resident on (MONTH) 22, (YEAR) at approximately 9:00 a.m. revealed the catheter bag to be uncovered hanging on the side of the bed visible from the hallway. Observation on (MONTH) 24, (YEAR) at 10:25 AM revealed the resident in his wheel chair in his room. The catheter bag, without privacy cover was observed hanging on side of chair. The facility failed to follow the plan of care for the use of an indwelling catheter. 28 Pa. Code: 211.11(a) Resident Care Plan previously cited 4/20/2017 28 Pa. Code 211(d)(1)(5) Nursing Services previously cited 4/20/17, 5/09/16

Based on observation and staff interview it was determined that the facility failed to provide aseptic technique with gloves and maintence of an eye wash device (Resident R168). Findings include: Observation of the medication pass on (MONTH) 22, (YEAR) at approximately 9:10 a.m. revealed Employee E6, registered nurse, to don vinyl gloves in Resident R168's room. The resident's plastic oxygen tubing was observed to be on the floor. Employee E6, picked it up off of the floor, potentially contaminating the vinyl gloves, disconnected it from the wall mounted oxygen, using both hands, folded up the tubing and put it in the trash can, removed a wipe from the medication cart drawer and placed it on top of the medication cart, obtained a tissue and handed to Resident R168, folded up a towel and placed it behind Resident R168's neck, checked the resident removed a new cannula from the package, placed it on the resident and connected it to the wall mounted oxygen, then threw away the plastic packaging form the cannula and removed the soiled gloves. The initial tour of the loading dock area on (MONTH) 21, (YEAR) at approximately 930 a.m. accompanied by the Chef and Clinical Nutrition Manager on revealed a wall mounted emergency eye wash station (to remove hazardous substances from eyes) next to a utility sink. The sink was noted to be soiled, the flip top dust covers were not in place and an insect was observed in the sink. These observations were confirmed by the by the Chef . The facility failed to provide aseptic technique related to use of gloves and maintence of an eye wash device. 28 Pa.Code:211.12(d)(1)(2)(5)Nursing services. previously cited 4/20/2017

Based on staff interviews and clinical record review; it was determined that baseline care plans for 2 of 12 clinical records reviewed did not address immediate or post surgical needs of the residents and one record contained conflicting or inaccurate interventions. (Residents R156, R 153, R158) Findings: Resident R158 was admitted to the facility on (MONTH) 12, (YEAR). [DIAGNOSES REDACTED]. On (MONTH) 11, (YEAR) the resident had a surgical procedure to alleviate pain due to a compressed nerve in the spine and surgical filling of a collapsed vertebrae to stabilize the bone. The plan of care did not address the care and treatment of [REDACTED]. Resident 156 was admitted on (MONTH) 18, (YEAR). [DIAGNOSES REDACTED]. At the time of the resident's interview, she exhibited pressured speech and was some what anxious. The clinical record revealed that the resident receives an antidepressant, an anxiolytic, and medication for sleep. The plan of care did address the resident mood and behavior. Resident 153 was admitted to facility on (MONTH) 14, (YEAR) with a [DIAGNOSES REDACTED]. Resident interview revealed that she was not able to lay down in bed and she did not have a catheter in her bladder. Review of the plan of care indicated that the head of bed should be less than 30 degrees but in another section of plan of care, it was written that the head of bed should be maintain greater than 30 degrees. The plan of care also indicated that the resident had a indwelling catheter however it had been discontinued on (MONTH) 16, (YEAR). Resident 162 was admitted on (MONTH) 10, (YEAR). [DIAGNOSES REDACTED]. Observation of the resident during the initial tour of the nursing unit on (MONTH) 21,2018 at approximately 12:30 p.m. revealed resident in bed, a dressing to the upper mid chest area visible. The resident stated at that time that staff had given her a cough pillow to hug when coughing or moving. The plan of care did not include interventions to address the care of the incision, and did not include interventions to address the potential for infection of the surgical incision. Employee E2 confirmed the findings on (MONTH) 24, (YEAR) at approximately 11 a.m The facility failed to develop baseline care plans that addressed immediate needs of the resident, that incorporate rehabilitation instructions and that contained accurate information. 28 PA Code: 211.11 (a)(b)(c)(d)(e) Resident care plan 28 PA Code: 211.12 (d)(1)(2)(3)(5) Nursing services previously cited 4/20/17, 5/09/16

Based on review of facility policy, observations and staff interviews, it was determined that the facility failed to prepare, serve and store food items under sanitary conditions. Findings include: Review of facilty policy titled Food Services Infection Control Policy effective date September 1, 2013 stated purpose was to minimize the possibility of contamination by maintaining a clean and safe work area. It stated further, beard guards are required for staff with facial hair, the ice scoop is stored in a storage container outside the ice machine when not in use, the kitchen floors are cleaned daily on the last shift, the food and nutrition supervisors monitor the floor continuously throughout the day. Additionally, the policy stated that cardboard boxes are placed in the white mobile bin in the receiving area of the kitchen. During the initial tour of the kitchen on April 18, 2017 at approximately 11:30 a.m. accompanied by the Dietary General Manager revealed the following: Observation of the walk-in freezer revealed icicles were on the condenser that appeared to be approximately 8 to 10 inches in length. A small area of ice and paper and debris was noted on the floor. A storage rack was noted to have light yellowish substance on it. The walk-in produce refrigerator had a build up of dust on the back of the condenser that was directly over fresh produce (apples, leeks and parsley). The inside of the light box had several small circular areas of a black colored substance. The Dietary General Manager confirmed these observations. The walk-in meat cooler was observed to have a large area of water on one side of the floor. The Dietary General Manager stated at that time that he did not know where the water had come from. In the food service area an ice machine was observed with the ice scoop in the ice. A kitchen staff member was observed, at that time, to walk to the ice machine and remove the scoop. A metal storage shelf was noted next to the tray line area that contained a tray of uncovered plastic, clean drinking glasses. Several of the glasses were noted to be standing up with the top rim uncovered. Directly next to the shelf a cardboard box-top had been placed where various small items such as tea bags, small plastic lids, jelly packets were being placed. The Dietary General Manager stated at that time that he did not know why staff were storing the items there and the glasses should not have been like that. Observation of the dry storage room revealed soiled floors. Pieces of pretzels, a dried grape tomato, cereal, small condiment packages and other debris was noted on the floor under shelves and in the corners of the room. Under a shelf that contained honey and BBQ sauce, spillage was noted. The kitchen receiving area was noted, directly outside the main entrance to the kitchen. the floor and wall was noted to be covered with build up from debris. The wall in the area was noted to have a build up of dust and dried splashes. The floor was also soiled with spots, and debris such as hairnets, cups and plastic packets. A large white bin was noted that was identified as a container for cardboard boxes. Inside the bin were crackers, pieces of fruit, food spillage, pieces of aluminum, paperclips and small pieces of splintered wood were observed. Outside on the loading dock, next to the dumpster, a garbage tote (large trash recepticle) was observed to be uncovered and contained items of trash such as multiple soiled vinyl gloves, styrofoam cups, water and other debris. The Dietary General Manager stated at that time that the tote should have been covered. Observation of the dietary department on April 19, 2017 between 10:00 a.m. and 10:30 a.m., in the food service area, an ice machine was observed with the ice scoop in the ice. In the main kitchen the ice machine was observed with the ice scoop in the ice. A member of the dietary staff was observed to walk over to the machine and remove the scoop. In the dishwashing area of the kitchen 2 staff members were observed to have facial hair and were not wearing beard restraints. The facility failed to store, prepare and/or distribute food in a sanitary manner accordance with professional standards for food service safety. 483.35(i) Sanitary Conditions. Previously cited 5/9/2016. 28 Pa. Code 201.14(a) Responsibility of licensee. Previously cited 5/9/2016. 28 Pa. Code 211.6 (f) Dietary services.

Based on staff interviews and clinical records reviews, it was determined that the failed to ensure that the resident's expressed choice, related to an advance directive, was reflected in the physician's orders [REDACTED]. (Resident R2, R4, R8, R9, R7 and R10). Findings include: Resident R4 was admitted to the facility on [DATE] with [MEDICAL CONDITION] (excessive body/lung fluid caused by a weakened heart muscle) and left leg [MEDICAL CONDITION] (inflammation of skin). It was noted on the electronic record and in the social service assessment that he had an advanced directive but it was not in the medical record. Documentation regarding resident's choice for life sustaining treatment was not indicated in the electronic record or on the physician's orders [REDACTED]. Interview with the Clinical Coordinator, Employee E2 On [DATE] at approximately 12 pm. If the resident has an Advanced Directive but it is not with them then the nurse will request that the resident have the document brought to the facility. If the document is not available then there is nothing that they can do. Resident R9 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident R9 had an Advance Healthcare Declaration (legal document in which a person specifies what actions should be taken for their health if they are no longer able to make decisions for themselves). A review of the document indicated that the resident did not want to be resuscitated and did not want any life sustaining treatments. The physician did not indicate on the physician order [REDACTED]. Interview the Clinical Coordinator, Employee E2 on [DATE] approximately 12:00 pm. Employee E2 stated that it is up to the physician to review the Advance Directive and to write an order. Resident R8 was admitted to the facility on [DATE] with left total knee arthroplasty (surgical knee reconstruction or replacement of joint) and [MEDICAL CONDITION] arthritis (chronic [MEDICAL CONDITION] disorder). She did not have an advance directive. According to the facility's policy: Advance Directives (dated [DATE]) upon admission, information on advance directives will be provided by Social Service Coordinator. There was no documentation that advance directive information was provided to the resident by Social Service Coordinator or that life sustaining treatment options were discussed by the physician. The physician did not indicate on the physician order [REDACTED]. Interview with Emloyee E5, the Social Service Coordinator on [DATE] at approximately 1:00 pm regarding who was responsible for the Advance Directives, Employee E5 stated that if the resident comes with an Advanced Directive, it is placed in the medical chart. It is the nurse's responsibility to inquire of the resident if they have an Advance Directive or if they want information. If the resident has an Advance Directive at home then the nurse will request over a two day period that they bring it to the facility. Employee E5 did not state that she talks to the residents regarding Advanced Directives or offers information on Advanced Directives for those residents that request it. Review of Resident R7's clinical record it was revealed that the resident had an Advanced Directives dated [DATE], that if the resident was in a terminal (end of life) state, he did not want resuscitation (emergency measures i.e.; CPR (cardiac/heart, [MEDICAL CONDITION]/lung resuscitation). The resident's Pre Admission Evaluation dated [DATE] under Advance Directives was blank. Review of Resident R7's physician's orders [REDACTED]. There was no documentation available of why the resident who wished to be a DNR (do not resuscitate) was now a Full Code. Review of Resident R10's clinical record revealed that the resident's Pre Admission Evaluation dated [DATE] under Advance Directives was blank. Review of Resident R10's physician's orders [REDACTED]. A review of Resident R2's clinical record revealed that the resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident R2's advanced directive, originally signed by the resident on [DATE] that revealed regarding end of life matters that the resident requested that her life not be prolonged in a hopeless situation. Further, on [DATE], resident R2 had written by hand and initialed Important: Do not resuscitate (DNR) if I do not have a quality of life assurance. Review of the physcian admission orders [REDACTED]. There was no evidence available for review at the time of the survey that staff had discussed or clarified the advanced directives with resident R2. The Director of Nursing stated in an interview on [DATE] at approximately 12:00 p.m. that a resident is considered a full code unless they are noted to be in a terminal condition even if they have an advanced directive that states otherwise. This facility practice could go against the resident's wishes at the end of life care. The facility failed to establish a process to consistently obtain, clarify and/or document the resident's instructions as it relate to the provision of health care when the individual becomes incapacitated. 28 Pa Code: 201.29 (a) (d)Resident rights. 28 PA Code: 211.12 (d)(3)(5) Nursing services.

Based on observation, clinical record review, staff interview and review of facility policy and procedure it was determined that the facility failed to provide aseptic technique related to wound care, handwashing and maintence of an eye wash device. (Resident R9). Findings include: Observation of Employee E4, licensed nurse, during medication administration pass, on April 19, 2017 at 8:20 a.m. revealed that when the nurse washed her hands, there was no paper towel used to turn off the faucet and during an observation of the same nurse on April 19, 2017 at 12:30 p.m. in the dining room again washed her hands and did not use a paper towel to turn off the faucet. Review of the facility's policy and procedure titled Hand Hygiene dated/revised November 27, 2013, Hand Hygiene Technique: d. Use towel to turn off the faucet, and dispose of the paper towels in the waste receptacle. This practice places residents at risk for cross contamination of infection by the nurse. On April 19, 2017 at 8:15 am, Employee E6 was observed giving wound care for Resident R9. Resident R9 was admitted to facility on March 27, 2017 with stage III decubitus ulcer on the left hip. Other [DIAGNOSES REDACTED]. The resident had finished eating his breakfast, before wound care, and the breakfast tray sat on the bedside table. Employee E6 turned the tray around on the table to make room for the dressing supplies. Prior to opening and placing the sterile gauze package and [MEDICATION NAME] border dressing on the table, Employee E6 did not remove the breakfast tray off of the bedside table; clean the table or place a sterile barrier on the table. The initial tour of the loading dock area on April 18, 2017 at approximately 11:30 a.m. revealed a wall mounted emergency eye wash station (to remove hazardous substances from eyes) next to a utility sink. The sink was noted to be soiled, the flip top dust covers were not in place and a soiled rag had been left in the sink. These observations were confirmed by the Dietary General Manager. The facility failed to provide aseptic technique related to wound care, handwashing and maintence of an eye wash device. 483.65(b) Infection Control; Spread of Infection. Previously cited 5/9/2016. 28 Pa.Code:211.12(d)(1)(2)(5)Nursing services.

Based on clinical record review, interviews with staff and review of facility documentation, it was determined that the facility failed to follow the appropriate protocol for unclogging a Peripherally Inserted Central Catheter line (PICC-a device implanted to deliver medications, fluids directly into the bloodstream and the heart) resulting in harm, for one of two residents reviewed (Resident R1). Findings include: A review of Resident R1's clinical record revealed that the resident had been admitted to the facility on [DATE], for care after a left knee revision (repair of a previous knee replacement). The resident was receiving antibiotics (medications used to treat an infection) through a PICC line for a left knee infection. Review of the facility documentation dated February 19, 2016, revealed that Resident R1 had received the incorrect medication via the incorrect route (how a medication is administered i.e., oral, into a vein (intravenously), cream applied to skin, drops instilled into eyes, etc.) Review of the facility policy titled, Guidelines for Cathflo [MEDICATION NAME], (medication used in the management of occluded access catheters - such as PICC lines), dated March 1, 2000, described the procedure for administration of Cathflo [MEDICATION NAME] for declotting long term care of venous catheters and [MEDICAL TREATMENT] catheters. The guidelines included that a physician's order is needed to initiate protocol, double verification will be performed by two Registered Nurses, or one Registered Nurse and one physician. If the central line is partially occluded (sluggish line, ability to infuse fluid but not withdraw blood) or completely occluded (inability to infuse fluid and withdraw blood) instill Cathflo [MEDICATION NAME] two milligrams/two milliliters. Double verify the order, drug and the patient prior to instillation. An interview with Employee E3, a Registered Nurse, on March 7, 2016 at 9:45 a.m., revealed that the employee was attempting to administer the antibiotic through the PICC line on February 19, 2016 at 9:51 a.m. Employee E3 was not able to instill the antibiotic due to the PICC line being blocked. Employee E3 called the physician who instructed her to call the pharmacy and see what the protocol was for declotting (unblock) a PICC line. Per Employee E3, she did not review the facility policy for declotting the PICC line, nor did she consult the supervisor or another nurse regarding the policy for declotting the PICC line. Per instruction from the pharmacist, Employee E3 wrote the verbal order as follows: [MEDICATION NAME] (Sodium [MEDICATION NAME]) with [MEDICATION NAME] to open PICC line stat, ([MEDICATION NAME] (used in the management of stomach secretions, acid in the stomach and management of overdoses of certain drugs) with [MEDICATION NAME] (used as a replacement therapy in absorption problems by pancreatic insufficiency) to open PICC line stat (immediately)). Employee E3 did not call the physician to verify the order. The medication was sent to the unit from the pharmacy. According to Employee E3, the following medications arrived from the pharmacy and were labeled and packaged separately with the following instructions: [MEDICATION NAME], 4200 unit cap, mix with 325 milligrams, Sodium [MEDICATION NAME] in 10-15 milliliters water to open PICC line. The other label read, Sodium [MEDICATION NAME], dose 325 miligrams, mix with [MEDICATION NAME] tab in 10-15 milliliters water to open PICC line. Per Employee E3, the following was done: Sodium [MEDICATION NAME], one tablet, 325 milligrams and [MEDICATION NAME], 4,200 unit capsule (one capsule) were then crushed and mixed with 10 to 15 milliliters of Sterile Water (per the instructions from the pharmacist) and instilled into the PICC line. During the interview with Employee E3, it was confirmed that Employee E3 did not call the physician to verify the order with him. Also revealed during the interview was that Employee E3 failed to follow the facility policy on double verification with another Registered Nurse that the correct medication was being given for declotting a PICC line. The medication was administered to Resident R1 on February 19, 2016 at 9:51 a.m., and one minute after the administration of the medication, Resident R1 was able to ring her call bell before becoming unconscious. A rapid response team (a team of highly trained staff able to respond to an emergency including nurses, physician, intensive care nurses and the Director of Nursing) responded. The resident was sitting in her wheelchair when she started to lose consciousness and was transferred to her bed. The resident lost control of her bladder and bowels and was vomiting. The resident was sent to the Intensive Care Unit (ICU) on February 19, 2016, with emesis (vomiting) and [MEDICAL CONDITION] (low blood pressure). The resident remained in the ICU until February 21, 2016. In an interview with Employees E4 and E5, Pharmacy Supervisors, on March 7, 2016 at 11:35 a.m., it was revealed that Employee E9, the Pharmacist, should not have initialed (written) his initials as a second check on the medication label of the medication that he prepared. Another pharmacist should have double checked the medication on the Sodium [MEDICATION NAME] labels. The medication should have been checked by a different pharmacist. In an interview with Employee E4 and Employee E5, on March 7, 2016 at 11:35 a.m. they confirmed that the protocol for checking medication was that two different pharmacists would check the medication and two pharmacists would sign the verbal medication order. Employee E4 and E5 stated that they use the same policy, facility policy titled, Guidelines for Cathflo [MEDICATION NAME] as stated above. A review of the verbal telephone order dated February 19, 2016, revealed the following order: [MEDICATION NAME] with [MEDICATION NAME] to open PICC line stat. The written initials of Employee E7 and Employee E9, both Pharmacists, were on the order form. An interview with Employee E7 on March 7, 2016 at 1:00 p.m., revealed that the second written initial was his. When asked when he had double checked /verified the order, Employee E7 stated he verified the order after the medication had been delivered to the unit. In an interview with Employee E7 on March 7, 2016 at 1:00 p.m., he was unable to state how the incorrect medication and incorrect route was not identified. The surveyor was unable to interview Employee E9 as the employee no longer works at the facility. The facility failed prevent actual harm to one resident by preventing the resident from receiving the incorrect medication by an incorrect route. 28 Pa Code: 201.18 (a)(b)(1)(3) Management. 28 Pa Code: 211.12(d)(1)(5) Nursing services.

Based on observations, clinical record review, interviews with staff and review of facility documentation, the facility failed to follow facility protocol and include accessory and cautionary instructions regarding the correct medication and correct route for one of two residents reviewed, who received medications through a Peripherally Inserted Central Catheter line (PICC-a device implanted to deliver medications, fluids directly into the bloodstream and heart), resulting in actual harm, due to the fact that the medication was not intended for administration through the PICC line (Resident R1). Findings include: A review of Resident R1's clinical record revealed that the resident had been admitted to the facility on [DATE], for care after a left knee revision (repair of a previous knee replacement). The resident was receiving antibiotics (medications used to treat an infection) through a PICC line for a left knee infection. Review of the facility documentation dated February 19, 2016, revealed that Resident R1 had received the incorrect medication via the incorrect route (how a medication is administered i.e., oral, into a vein ( intravenously), cream applied to skin, drops instilled into eyes, etc.) Review of the facility policy titled, Guidelines for Cathflo Activase, (medication used in the management of occluded access catheters) dated March 1, 2000, described the procedure for administration of Cathflo Activase for declotting long term care catheters: venous catheters and dialysis catheters. The guidelines indicated: the purpose of this policy is to describe the procedure for administration and the protocols for the care of the patient receiving Cathflo Activase for declotting long term catheters. Definition: Cathflo Activase is a tissue plasminogen activator (used in preventing clot formation). One of the indications for the use of Cathflo Activase is the management of occluded access catheters. Policy: A physician's order is needed to initiate the protocol. The medication may be instilled in the designated catheter by the nurse. Double verification of Cathflo Activase will be performed by two Registered Nurses, or one Registered Nurse and one physician. Mixing Cathflo Activase: The pharmacy dispenses Cathflo Activase in a vial to be reconstituted as directed by the company (2.2 milliliters Sterile Water/two milligrams Cathflo Activase vial). Procedure/Protocol: If the central line is partially occluded (sluggish line, ability to infuse fluid but not withdraw blood) or completely occluded (inability to infuse fluid and withdraw blood) instill Cathflo Activase two milligrams/two milliliters. Double verify the order, drug and the patient prior to instillation, as stated in the facility policy. An interview with Employee E3, a Registered Nurse, on March 7, 2016 at 9:45 a.m., revealed that the employee was attempting to administer the antibiotic through the PICC line, on February 19, 2016 at 9:51 a.m. Employee E3 was not able to instill the antibiotic due to the PICC line being blocked. Employee E3 called the physician who instructed her to call the pharmacy and see what the protocol was for declotting (unblock) a PICC line. Per instruction from the pharmacist, Employee E3 wrote the verbal order as follows: bicarb (Sodium Bicarbonate) with Pancreaze to open PICC line stat (immediately). The medication was sent up to the unit from the pharmacy. Per Employee E3 the following medications, Sodium Bicarbonate (used in the management of stomach secretions, acid in stomach and the management of overdoses of certain drugs) one tablet, 325 milligrams and Pancreaze (used as a replacement therapy in the treatment of [REDACTED]. During the interview on March 7, 2016 at 9:45 a.m. with Employee E3, it was confirmed that Employee E3 did not call the physician to verify the order with him. Also revealed during the interview was that Employee E3 failed to follow the facility policy on double verification with another Registered Nurse that the correct medication was being given for declotting a PICC line. The medication was administered to Resident R1 on February 19, 2016 at 9:51 a.m., and one minute after the administration of the medication, Resident R1 was able to ring her call bell before becoming unconscious. A rapid response team (a team of highly trained staff able to respond to an emergency- nurses, physician, intensive care nurses and the Director of Nursing) responded. The resident was sitting in her wheelchair when she started to lose consciousness and was transferred to her bed. The resident lost control of her bladder and bowels and was vomiting. The resident was sent to the Intensive Care Unit (ICU) on February 19, 2016, with emesis (vomiting) and hypotension (low blood pressure). The resident remained in the ICU until February 21, 2016. A review of the labels that accompanied the medication read as follows: Pancreaze 4200 unit cap mix with 325 mg. (milligrams) Sodium Bicarbonate in 10-15 ml (milliliters) water to open PICC line. The other label read: Sodium Bicarbonate dose 325 mg. (milligrams) mix with Pancreaze tab in 10-15 ml. (milliliters) water to open PICC line. Both packets were dated February 19, 2016, and initialed (typed) by Employee E9, the Pharmacist. Both packets had a second written initial. The Sodium Bicarbonate had a written initial of Employee E9, as verified by his supervisor in an interview on March 7, 2016. The second medication, the Pancreaze had a written initial that Employees E4 and E5, both Pharmacy Supervisors, did not recognize. In an interview with Employees E4 and E5, both Pharmacy Supervisors, on March 7, 2016 at 11:35 a.m., it was revealed that Employee E9, the Pharmacist, should not have initialed (written) his initials as a second check on the medication label of the medication that he prepared. Another pharmacist should have double checked the medication on the Sodium Bicarbonate labels. The medication should have been checked by a different pharmacist. During the interview it was confirmed that Employees E4 and E5 did not recognize the written signature used as a second check to the Pancreaze. In an interview with Employee E4 and Employee E5, on March 7, 2016 at 11:35 a.m. they confirmed that the protocol for checking medication was that two different pharmacists would check the medication and two pharmacists would sign the verbal medication order. Employees E4 and E5 stated that they use the same policy, facility policy titled, Guidelines for Cathflo Activase as stated above. A review of the verbal telephone order dated February 19, 2016, revealed the following order: bicarb with Pancreaze to open PICC line stat. Written initials of Employee E7 and Employee E9 were on the order form. An interview with Employee E7, a Pharmacist, on March 7, 2016 at 1:00 p.m., revealed that the second written initial was his. When asked when he had double checked/verified the order, Employee E7 stated he verified the order after the medication had been delivered to the unit. During the interview with Employee E7 on March 7, 2016 at 1:00 p.m., he was unable to state how the incorrect medication and incorrect route was not identified. The surveyor was unable to interview Employee E9 as the employee no longer works at the facility. The facility failed to include the cautionary warnings regarding medication administration and route resulting in actual harm to Resident R1. 28 Pa Code: 211.9 (a) (1) Pharmacy services.